Integrated case management

Five sites have been provisionally identified as physical locations where multi-disciplinary community services can be based.  There will be 2 in Canterbury and 1 in Whitstable, Faversham and Ash (covering Ash and Sandwich).

GPs at the Community Hub Operating Centres (CHOCs) have identified patients who are most likely to benefit from having a team around them. A team of professionals,  from different disciplines; mental health, social care, community nursing, voluntary organisations, GPs etc.  are working together to help make sure that the identified patients have a joined up care plan, which meets their needs, and focuses on keeping them well at home in order to avoid being admitted to hospital.  Sharing knowledge means that gaps which may have occurred previously, are being picked up and acted upon. These teams work with specific patients for short periods of time, known as “step up care”, helping avoid hospital admission. Once everything is in place they then ‘step down’ into normal care.

All members of the team are involved in developing a robust care plan which is ultimately agreed and owned by the patient and reflects their own goals. The added value of having availability of social prescribing is proving a valuable asset in the process; as it aids identification of other areas for action, such as anticipating carer breakdown and / or other social care issues, which if not addressed may lead to the need for hospital or care home admission.

They are also looking at the best way of using IT to support the safe sharing of appropriate data for these patients between the different agencies who support them.

A ten week pilot of this project, working with 50 patients, has now been completed and the positive impact on patients’ health and satisfaction with the service they have received has led to encompass rolling the project out more widely.

Certain services are usually only available in hospital settings, but there could be capacity to deliver them more locally by GPs.

Encompass is working with GPs to increase on the success of having ear nose throat (ENT) and epilepsy services within GP practices, and is now looking at other specialities bring care into the community.

Social prescribing is looking at a person’s needs and helping them access, not tablets or formal health support, but other support or ways of helping their condition such as local support and community groups.

For mental health conditions, and for age related conditions such as loneliness and social isolation, medication may sometimes not be the most appropriate course of action. It may be that some patients would be better served by attending a group or accessing a community service.

Working with Red Zebra, a voluntary sector umbrella organisation, the project means that they have access to almost 400 voluntary and care organisations in the local community. Two social prescribers are in place and another is being recruited to who will signpost people to the most appropriate service.


To view services available in your area visit Connect Well Kent

Encompass wants to ensure that patients receive the right care, in the right place, at the right time. They are working in partnership with Kent Community Health NHS Foundation Trust, with developing specialist wound medicine centres of excellence and integrated wound care processes and procedures between community and GP practices. Using advanced computer software they are able to scan wounds and track progress on healing rates and on the use of the most appropriate dressings to apply to the wound. The hand held devices mean that an image can be taken of the wound and in the presence of the patient, which can be sent to a specialist Tissue Viability Nurse, for a second opinion if necessary. The results to date have been extremely positive with healing rates reducing dramatically and quality of life much improved.

Another initiative is the introduction of the community catheter clinics. A frequent cause of hospital attendance is when people have catheter related problems. This can cause infection which in turn can lead to further complications.

Catheter clinics started at Faversham from April 2016, Whitstable from May 2016 and Canterbury from July 2016 and continue to see patients with community setting for catheter related issues, who would otherwise attend A&E.

At end of February 2017, 174 patients were seen in the Catheter service.

Another clinic is planned for Bridge Surgery, which now has capacity to release a practice nurse, to train in catheter care.

Encompass is projecting a saving of 224 admissions (£150k) in 2017/18.

The community paramedic project was one of the first to be rolled out by encompass, working with the South East Coast Ambulance Service NHS Foundation Trust (SECamb). This project meant that GPs were able to send community paramedics to home visits rather than attending themselves. The result of this was two-fold, GPs are able to spend more time in practice, and patients who need a home visit get seen more quickly.

Since this project was rolled out in November, 4,500 patients have received home visits and the ambulance conveyed A&E attendance reduced by 5.5% at its peak. Both patient and practice satisfaction with the service was high.


The pilot has now finished and, using the data gathered, Encompass are looking at ways to develop the service sustainably for the future.